Chronic traumatic encephalopathy:
Rugby's call for clarity, data and
leadership in the concussion debate
Jon S Patricios, 1• 2• 3 Simon Kemp4
AMERICAN FOOTBALL FIRST...
After US District Judge Judy Brody
recently ruled that the consolidated multidistrict concussion litigation cases against
the National Football League (NFL) in the
USA were to be transferr ed to a labour
arbitrator, the NFL agreed to a $765
million settlement. More than
4000
current and ex-NFL players, the plaintiffs
in this case, allege that the NFL has misrepresented the long-term health dangers
associated with on-field head injuries. 1
Either way, the debate about the potential
long-term consequences of concussion
will play out in the American media for a
number of years to come, ensuring that
the term chronic traumatic encephalopathy (CTE), a progressive neurodegenerative condition that is thought to occur as a
consequence of repetitive mild traumatic
brain injury, not only remains part of our
clinical lexicon, but is also embedded in
social media postings ('#CTE' on Twitter,
'Heads Up! CTE' on Facebook , 1740
YouTube videos, and 740 000 Coogle
references) 1 3 where the messaging today
is simple and consistent: 'contact sport
damaged my brain and it didn't have to
happen' .
... ICE HOCKEY FOLLOWS ...
Recently, the National Hockey League
(NHL) has been sued by the family of a
former NHL player in what has been
described as 'an explosive wrongful death
lawsuit' that allegedly resulted from a
lethal combination of recurrent
head
injuries, in-game fighting, over-prescribed
painkillers and CTE. American Football
and Ice Hockey are not the only sports to
be associated with CTE.4 Boxing was
implicated in the very first medical
descriptions of dementia pugilistica in
prize-fighters in 1928/ while in soccer,
'South African Rugb Union (SARU), Newlands, Cape
Town, South Africa; Section of Sports Medicine,
Faculty of Health Sciences, University of Pretoria,
Pretoria, South Afr ica; 3Department of Emergency
Medicine, Faculty of Health Sciences, University of the
Witwate rsrand, Johannesburg, South Afr ica; •Rugby
Football Union, Twickenham, UK
Correspondence to Dr Jon S Patricios, South African
Rugby Union (SAR U), Newlands, Cape Town 2 12 1,
Sout h Africa; jpat@mweb .co.za
the possibility of significant brain injury as
a result of repeated heading of the ball
has again been reopened in the context of
the CTE debate. 6
...WILLRUGBYUNION?
Rugby Union (hereafter just 'Rugby') is a
collision team sport played by men,
women, boys and girls in more than 100
countries across five continents. The
seven-a-side version of the game will
return to the Olympic Games in Rio in
2016 and is anticipated to be the catalyst
for a further expansion of the game
around the world. The game's origin is
attributed to a young schoolboy at Rugby
School in England who, while playing
soccer "with fine disregard for the rules
of football ... first took the ball in his
arms and ran with it, thus originating the
distinctive feature of the Rugby game."7
While running with and passing the ball
are key features of the game, the contest
for possession which is embedded in the
game's charter8 is most clearly seen in the
frequent contact events that characterise
the modern game. Forceful tackling of the
ball carrier by the tackler or tacklers,
aiming to drive him/her backwards is an
integral part of the game (http://www.
sportsconcussion.co.za/sportconcussion /
video-channeV#featured-yt-vids-page)
with in excess of 200 tackles being seen
each game. Although tackling that
involves contact above the shoulders of
the ball carrier is not allowed under the
Laws of the Game, the head and brain are
10
certainly not immune to trauma.9
Inadvertent head-to-head impacts occur,
as do head collisions with the ground and
opposition feet, hips and knees, accounting for a large proportion of concussions
seen in Rugby.
As sports medicine doctors who care
for Rugby players from the age of 6
onwards through to international professional players, the exponential growth in
CTE dialogue is both engrossing and
concerning.
Rugby is a sport that consists of static
and dynamic phases requiring strength,
speed and guile in different measure
according to posltton.
The
game
encourages players of a range of sizes,
shapes and skill levels to participate which
few other sports can match. Its inherent
physicality together with its core values of
respect, self-discipline and fair play are
key elements of the game's attraction to
players, coaches, spectators, broadcast ers
and sponsors. The health benefits of
regular sports participation, when society
is becoming increasingly sedentary, are
seen as increasingly important in optimising health and wellness. Rugby has an
excellent record in this regard .11
In all the cases of CTE described so far,
only two cases, who also participated in
other contact sports, have been associated
with Rugby. 12 13 Admittedly North
America doesn't have a strong Rugby
base, but it surely is only a matter of time
before a stronger association is claimed
and the conclusion suggested that participating in non-he lmeted, tackling sports
may have an adverse long-lasting effect on
the brain. Already there is ongoing discussion about the possible link between
Rugby and Amyotrophic Lateral Sclerosis
(ALS) in two retired South African international Rugby players. 14 15 Concern
about risk of sports injury is known to be
a key factor in the recruitment and retention of players into a sport with parental
perceptions of risk an increasingly critical
factor in age-group sport. It appears that
the current CTE debate in North America
has been picked up by parents with real
concerns expressed about the effect on
American Football and Ice Hockey
participation.
RUGBY'S RECORD ON RISK
MANAGEMENT
Rugby has never shied away from addressing player safety issues including head
injury and concussion. The sport has
increasi ngly adopted a mature risk management approach where discussion of risk
perception drawing on epidemiological
evidence has driven appropriate risk mitigation
initiatives. 16
Communication
throughout the process to the whole game
is standard practice. The game's approach
to concussion risk management has followed these principles. The International
Rugby Board (IRB) has been a sponsoring
attendee at the last two concussion in
Spor t Consensus Meetings, adopting
widely implem ented international concussion consensus protocols at all levels of the
game, and the IRB has a proven track
record of implementing sport-specific
national and local safety programmes. 17 A
u nique 'brain bin' known as the Pitch side
Suspected Concussion Assessment (PSCA)
is being trialed around the world to facilitate the immediate evaluation of elite
players suspected of having suffered a concussion during a match, and new agespecific concussion return-to-play guidelines are currently being drafted.
The typical risk management approach
relies on an informed whole sport perception of risk driven by data. To date,
Rugby has been able to base its risk management approach on appropriate data
sets and in cases where these have needed
enhancing, such as catastrophic cervical
injury, Rugby has moved swiftly to ensure
that data are collected.
Our concern is that, till date, the enormous public interest in CTE appears to
have been escalated by its high social
network visibility, increased public awareness and high-profile law suits, rather than
sound science. We believe that this
enhanced awareness may impact on participation rates in Rugby Union in spite of
an absence of evidence of established
risks. Indeed, if the risk is ultimately
found to be acceptable, reduced participation rates may actually have an adverse
effect on participants' overall health.
Equally, we recognise the need to robustly
and honestly challenge ourselves as Rugby
doctors, with questions pertaining specifically to our collision sport. This includes
assessing the extent to which the clinical
features attributed to CTE such as irritability, impulsivity, aggression, depression,
short-term memory loss and heightened
suicidality proposed to begin 8-10 years
after experiencing repetitive mild traumatic brain injury are prevalent in retired
Rugby playersY
Do we have a sense that one of the legacies of over 100 years of Rugby is a
cohort of neurologically compromised
and psychologically afflicted retired
players?
More specifically, since the introduction
of professionalism in 1995 (and the
accompanying increased playing schedule
and intensity at all levels of the game), do
we feel that the prevalence of symptoms
associated with CTE and psychological
conditions has increased?
Our experiences suggest that neither is
true.
CliNICAl AND COMMERCIAl
CONFOUNDERS TO CONSIDER
The strong possibility that confounding
variables that are recognised in (but are
not unique to) the NHL and NFL playing
populations and that might contribute to
CTE risk should be acknowledged. These
include vices associated with many professional sportsmen-the
physical
and
psychological effects of performanceenhancing drugs and the misuse of social
drugs including alcohol, as well as the psychological effects of retirement on onceprominent and well-rewarded sportsmen .
The incidence and prevalence of CTE in
the general and retired sporting population is still unknown, and our understanding that individual susceptibility is
influenced by genetics, comorbidities,
neuroplasticity and cognitive reserve is
20
still evolving. 18
There is convincing
evidence that previous concussion may
increase susceptibility to future concussive
injury/ 1 but a literature review looking at
the long-term neurocognitive effects of a
number of contact sports concluded that
adverse long-term neurocognitive effects
of concussive injury have been demonstrated empirically in professional boxers
only.22
In the absence of sufficient current and
historical game analysis, head and headgear impact force data comparing helmeted with non-helmeted sports, it is
hard to know how or if acute and cumulative concussive injury in Rugby differs
from that seen in the NFL and NHL and
what, if any, are the clinical consequences
of such differences.
EMPHASISING EPIDEMIOLOGY
When the term CTE was first coined m
2002 by Dr Bennet Omalu, an African
pathologist working out of Pittsburgh, the
initial reaction of the NFL was hostile.
Perhaps they perceived that the ethos and
possibly the commercial interests of the
game were being threatened . Since then, Dr
Omalu's work and interaction (http://www.
youtube.com/watch?v=pOKvhcBelwQ)
with his medical colleagues as well as the
publications from the Center for the Study
of Traumatic Encephalopathy in Boston
have refined the description of the histopathological features describing a predictable pattern of hyperphosphorylated tau
protein deposition in the brain, and an
associated accumulation of other abnormally aggregated proteins including TAR
DNA-binding protein, 't amyloid protein
and a-synuclein .13
Recent suggestions that advanced
imaging techniques may reveal encephalopathic changes in the living brain may be
the first steps towards a viable premorbid
clinical and research tool.23 Far more
ominous is the apparent tendency to be
drawing clinical conclusions (and staking
large law suits!) on postmortem histological evidence that cannot, by definition,
infer causality or enable us to move past
step one of van Mechelen's widely cited
and accepted injury sequence prevention
and intervention model, namely identifying the extent of the problem. 24
With respect to the long-term consequences of the head trauma in our sport,
we believe that we.are starting to experience a cultural shift away from a riskbased model to one where public opinion
driven by media reports based on powerful but limited epidemiological data and
understanding may be not only fuelling
adverse behaviours and compensatory
neurosis but also promoting symptoms
and anxiety in previously asymptomatic
athletes.
CAll TO CONSOliDATE
Rugby cannot side step this issue; it has
an obligation to provide clear leadership
around the risk of participation in the
sport. Our call is for a unified, considered,
consistent and unemotive message from
all stakeholders in collision sports to
define our current understanding of the
possib le neurocognitive effects of our
sports that addresses the following:
1. The extent to which sportsmen
involved in principally helmeted collision sports may suffer structural
changes in their brains that manifests
later in life with neurological and
psychological symptoms.
2. What the incidence or prevalence of
this condition in the general population as well as specific· sporting populations is.
3. What other medical and lifestyle
factors contribute to the development
of this condition.
4. How the risk of an individual developing this condition through participation in contact sports such as
Rugby Union compares to other
uncommon but highly adverse life
events such as sudden cardiac death.
5. How can the adverse health effects of
non-participation in sport be factored
into any risk-based decision-making
about participation?
6. To what extent can appropriate acute
medical management of head injuries
accompanied by suitable return-toplay guidelines decrease the chance of
long-term sequelae?
7. How can we work to ensure that
best-practice acute concussion management is actually being delivered
through a coordinated effort from a
number of groups? This must be a
priority in sports injury management
across collision sports.
8. How can we best counsel athletes suffering from recurrent
concussions
(three or more) or whose recovery
from the acute episode becomes
more prolonged so as to diminish the
possibility of longer term effects?
9.
How can we encourage sporting codes
to urgently initiate validated consensusbased epidemiologi cal surveys to help
ascertain the incidence of neurocognitive and psychological disorders in
retired sportsmen as compared with
the general population, allowing comparison between sports?
10. How can we encourage athletes
previously involved in collision sports to
donate their brains after death for
the benefit of research without bias?
11. How can we ensure that sports head
injury policy should be reviewed
regularly based on scientific progress?
12. How do we best develop sport-specific
risk management strategy involving all
of the key sport stakeholders to communicate clearly, loudly and consistently with the global community?
As physicians and scientists, we need to
reclaim clinical decision making from the
realm of media-driven and often frenzied
public opinion and help guide administrative decisions in sport for the immediate
and long-term benefit of the athlete.
Accepted 3 September 2013
Br J Sports Med 2013;0:1-3.
doi:l0.1136/bjsports-2013·093031
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